DENTAL ANESTHESIA COMPLICATIONS IN THE DENTAL CHAIR SAAD A. SHETA Assistant Professor Consultant Anesthesia Dental College KSU

Dental Anesthesia  Out-Patient Anesthesia (Dental Chair Anesthesia)  Day-Case Anesthesia  In-Patient Anesthesia  Complete Dental rehabilitation  Complicated oral surgery procedures  Major Maxillofacial surgeries  In addition, Sedation

Complications  Out-Patient Anesthesia (Dental Chair Anesthesia)  Sedation Techniques

Out-Patient Dental Anesthesia  Dental Chair Anesthesia  Out-Patient dental extraction  Children (4-10 years): high incidence of URTI  Steadily decreased

Out-patient Dental Anesthesia (Sedation) Patient Selection (&Indications ) ASA grade I&II Disability (mental& physical) Review:coexisting disease current medications Fearful adults rather sedation Procedureshort not so extensive

Out-Patient Dental Anesthesia (Sedation) Contraindications  Serious cardiopulmonary diseases  COPD  Diabetes or other endocrinological diseases  Neuromuscular disorders  Coagulopathies & Hemoglobinopathies  Marked oro-facial swelling (edema& trismus)  Potential difficult airways  Marked congenital heart defects  Extreme obesity  Drugs: MAOIs, Anticoagulant  Not fasting

Out-Patient Dental Anesthesia (Sedation) Equipment (Up to the standards of in-patient GA)  Dental Chair  Anesthetic Equipment  Monitoring  Resuscitation Equipment

 Dental Chair  Adjustable: horizontal (supine) Head down  Manual release  Adjustable head rest  Hospital out-patient:operating table

 Anesthesia Equipment  Continuous flow anesthesia machine  Quantiflex (Relative Analgesia)  Mouth props, packs, gags, nasopharyngeal airway, rubber dam  Separate suction unit  Scavenging system

 Monitoring  Pulse  ECG  NIBP  Pulse Oximetry  Capnography

 Resuscitation Equipment  Full range of tracheal tubes& accessories  Two working laryngoscope  IV agents: Succinylcholine& atropine  Emergency drugs  Defibrillator  Training: B&ALS

Out-Patient Dental Anesthesia Induction  Inhalational (mask) induction  Intravenous Induction

Out-Patient Dental Anesthesia Induction  Inhalational (mask) induction N 2 O/O 2 + Halothane Common, smooth Enflurane Less potent Isoflurane Respiratory irritation Sevoflurane New, smooth, less potent

Out-Patient Dental Anesthesia Induction  Intravenous Induction Advantages Avoidance of face mask Less salivation Less atmospheric pollution Disadvantages CV depression Drugs Methohexitone Low incidence of nausea & vomiting Good recovery Pain on injection, Involuntary movements, hiccups Propofol

Out-Patient Dental Anesthesia Maintenance  Inhalational agents/N 2 O  Nasal mask, mouth gag, pack  Maintain airway Posture(Supine Position)  Less hypotension  less bradycardia However  high risk of aspiration  Airway obstruction&  Decrease ERV

Out-Patient Dental Anesthesia Recovery  Left lateral position  100% O2  Suction Observation & monitoring  Discharge criteria  Instructions  Analgesia (NSAIDs)

Sedation It is a technique where one or more drugs are used to Depress the Central Nervous System of a patient thus reducing the awareness of the patient to his surrounding.

According to the degree of CNS depression: Conscious Sedation Deep Sedation General Anesthesia

Conscious Sedation It is a controlled, pharmacologically Induced, minimally depressed level of consciousness that retains the patient ’ s ability to maintain a patent airway independently and continuously and respond appropriately to physical and/or verbal command

Deep Sedation It is a controlled, pharmacologically induced state of depressed level of consciousness. from which the patient is not easily aroused and which may be accompanied by a partial loss of protective reflexes, including the ability to maintain a patent airway independently and/or respond purposefully to physical stimulation or verbal commands

General Anesthesia It is defined as : unconsciousness no response to pain labile vital signs GA is defined separately, however for the purpose of of describing management, the two phrases (GA & Deep Sedation) refer to one physiologic state

Sedation Fundamental Concepts  It is easy to drift from one state to another.  Patient state is considered in terms of the level of consciousness rather than the technique involved.

Sedation Fundamental Concepts  Sedation techniques are not pain-control techniques  One should guard against becoming comfortable with a single method. The treatment should fit the patient rather than the converse

Sedation Techniques Non Titrable Technique  Oral Sedation  Rectal Sedation  Intramuscular Sedation  Submucosal Sedation  Intranasal Sedation Titrable Technique  Inhalational Sedation  Intravenous Sedation Combination Of Two

Combination of Methods and Techniques Most complications occurred with polypharmacology in the hands of untrained personnel AUGMENTATION OF THE EFFECT + REDUCE THE DOSE OF STONGER DRUGS.

Dental Chair Complications  Respiratory Complications  Cardiovascular Complications  Allergic Reaction  Miscellaneous

 Respiratory Complications  Airway Obstruction  Respiratory Depression

 Respiratory complications Airway ObstructionRespiratory Depression Causes  Tongue  Blood, debris  Laryngeal spasm  Narcotics  Over-sedation Clinical Picture  A-W Obstruction  Hypoxia  Hypoventilation  Hypercapnia  Hypoxia Management  Patent airway  Oxygenation  Ventilation  Reversal Agents

Airway Obstruction Most common cause: tongue and/or epiglottis

Open the Airway P osition Jaw thrustHead tilt–chin lift

Open the Airway O ropharyngeal Airway

Open the Airway N asopharyngeal Airway

Open the Airway E ndotracheal Intubation “ Aligning Axes of the Airway ”

Open the Airway E ndotracheal Intubation “ Laryngoscopes ”

Open the Airway E ndotracheal Intubation “ Visualization of the Cord ”

Open the Airway L aryngeal M ask A irway (LMA)

Open the Airway E sophageal- T racheal C ombitube

Oxygenation Adjunct Devices

Ventilation Bag-Mask Ventilation  Key ventilation volume: “ enough to produce obvious chest rise ” 1 Person difficult, less effective 2 Persons easier, more effective

 Cardiovascular Complications  Hypotension  Bradycardia  Dysrhythmia  Fainting

 Hypotension Induction of anesthesia Carotid sinus compression Over sadation  Bradycardia Tooth extraction Halothane (nodal rhythm)

 Dysrhythmias (Tachy-arrhythmias) Aetiology (Tooth extraction)  High preoperative catecholamines  Light anesthesia  Airway obstruction & hypoxia  Halothane & local anesthesia  Local anesthesia with vasopressors Significance  Controversial  Significant with unexpected cardiac disease(viral myocarditis)

 Fainting CausesPrevious factors (CV, allergic,..) Emotional factors (more common) Aetiology limbic cortex-hypothalamus-reflex vasodilatation Increase parasympathetic activity-bradycardia Management Head down-leg elevated 100% O 2 Cessation of anesthesia

 Allergic Reaction Incidence  Very rare  More commonly (vaso-vagal, toxic reaction, epinephrine) Aetiology  Ig E-mediated reaction  Easter-linked: p-amino benzoic acid  Amide-linked: preservatives (Paraben)

Manifestations  Hypotension, tachycardia, arrhythmias  Bronchospasm, cough, dyspnea, pulmonary oedema, laryngeal oedema, hypoxia  Urticaria, facial oedema, pruritus

Management  Discontinue drug  100% O2  Epinephrine ( mg IV or IM)  Intubation  IV fluids (LRS 1-2 liters)  Diphenhydramine  Hydrocortisone (up to 200mg IV)

 Miscellaneous  Nasal Trauma, Epistaxis  Pulmonary Aspiration  Diffusion Hypoxia  Continued Bleeding  Post operative Sore Throat  Post operative Nausea & vomiting  Post operative Pain & swelling

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